ABSTRACT Mental health policymaking to support the implementation of evidence-based practices (EBPs) largely has been directed toward clinicians. However, implementation is known to be dependent upon a broader ecology of service delivery. Hence, focusing exclusively on individual clinicians as targets of implementation is unlikely to result in sustainable and widespread implementation of EBPs.
Policymaking that is informed by the implementation literature requires that policymakers deploy strategies across multiple levels of the ecology of implementation. At the organizational level, policies are needed to resource the added marginal costs of EBPs, and to assist organizational learning by re-engineering continuing education units. At the payor and regulatory levels, policies are needed to creatively utilize contractual mechanisms, develop disease management programs and similar comprehensive care management approaches, carefully utilize provider and organizational profiling, and develop outcomes assessment. At the political level, legislation is required to promote mental health parity, reduce discrimination, and support loan forgiveness programs. Regulations are also needed to enhance consumer and family engagement in an EBP agenda. And at the social level, approaches to combat stigma are needed to ensure that individuals with mental health need access services.
The implementation literature suggests that a single policy decision, such as mandating a specific EBP, is unlikely to result in sustainable implementation. Policymaking that addresses in an integrated way the ecology of implementation at the levels of provider organizations, governmental regulatory agencies, and their surrounding political and societal milieu is required to successfully and sustainably implement EBPs over the long term.

Implementation Science 2008, 3:26http://www.implementationscience.com/content/3/1/26Page 2 of 9(page number not for citation purposes)agencies, therefore, largely seem to be taking a clinicalapproach to the implementation of EBPs. Conversely, theemerging literature within implementation science sug-gests that implementation requires a systemic, or ecologi-cal, approach [1]. By ignoring this ecology, currentpolicymaking to support the implementation of EBPs isitself not evidence-based.In this article – directed toward policymakers and imple-mentation researchers in public mental health settings –we argue that mandating the use of EBPs by individual cli-nicians and provider organizations, or narrowly focusingon effecting change within individual organizations, isunlikely to result in their successful and sustainableimplementation unless the broader ecology within whichthese interventions are delivered is also supported. Fol-lowing a brief overview of this implementation ecology,we present a framework to operationalize this ecology andillustrate it in Figure 1. We end by highlighting potentialstrategies at each level of this framework that policymak-ers can deploy in order to support implementation ofEBPs and summarize these strategies in Table 1.The march toward evidenceQuality improvement within mental health services haslong been a goal of policy. Operationalization of qualityimprovement efforts has occurred largely at the level ofindividual clinicians and their clients through the devel-opment and deployment of specific interventions backedby research evidence, clinical judgment, and client prefer-ences. Pioneered at McMaster University as 'evidence-based medicine' [2,3], applications of this approach tomental health have resulted in various EBPs [4,5]. Thesepractices are often packaged with manuals and othermaterials suitable for demonstrating a particular practiceto clinicians [6-9].Policymaking directed toward mental health qualityimprovement evolved to support these clinical efforts.Government agencies have supported the developmentand use of clinical guidelines to standardize care [10,11].They also have released reports on various aspects of qual-ity [12] and have supported the widespread disseminationand use of evidence-based mental health interventions[7]. States have also incentivized (i.e., created a rewardstructure for using) EBPs – Oregon's passage of SB 267 in2003 requiring the state to spend an increasing share of itsbudget in purchasing specified interventions is one exam-ple [13]. States also have required the use of particularclinical protocols (e.g. Texas' emphasis on the use of med-ication algorithms) [14]. The District of Columbia'sDepartment of Mental Health has adopted a policy to sup-port 'evidence-based psychotherapy,' which requires thatall psychotherapy provided to clients in the DistrictA Policy Ecology of ImplementationFigure 1A Policy Ecology of Implementation.

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Implementation Science 2008, 3:26 http://www.implementationscience.com/content/3/1/26Page 3 of 9(page number not for citation purposes)appear on a list maintained by the department [15].Today, the number of individuals receiving interventionsthat are evidence-based is one of the Substance Abuse andMental Health Services Administration's (SAMHSA)National Outcome Measures [16]. Efforts by governmen-tal agencies to improve quality in Britain [17], Brazil [18],and Germany [19], to name a few examples, have alsobeen largely focused at the clinical level.DiscussionThe ecology of implementing EBPsIn FY 2005, SAMHSA began funding mental health trans-formation state incentive grants [20,21]. In terms of pol-icy, these grants marked a shift in thinking fromincentivizing the development and deployment of spe-cific interventions, to incentivizing the infrastructure nec-essary for appropriate service delivery. This shift in policywas to some degree influenced by the wealth of literaturethat has accumulated in recent years on institutionalframeworks [22,23] and organizational factors that canguide implementation efforts [24-26]. This literature sug-gests that, although the clinical encounter is where EBPsare delivered, efforts to promote the implementation ofsuch practices should focus on the wider context of servicedelivery [24,27,28]. Collectively, this literature articulatesan ecology of mental health intervention ranging from theclinical encounter to the social context of mental healthservice delivery. As articulated by Vijay Ganju [29]:This perspective goes beyond the adoption of the EBPby an individual practitioner or organization andincludes the notion of broader, systemwide availabil-ity of EBPs and their integration into existing systemsof care. ... The model that emerges related to the ulti-mate, broad based adoption depends on the nature ofthe EBP ..., the consumer ..., the practitioner ..., theorganizational matrix within which the practitioneroperates ... and the public mental health authority, orpurchaser .... The implication is that each of these lev-els must be adequately addressed for sustained, sys-temwide uptake of an EBP.Implementation spans the set of activities necessary tosuccessfully and sustainably apply with high fidelity anintervention of known efficacy within community-basedclinical settings. These activities are contextual, involvingthe organization within which services are delivered, theregulatory and funding environment operant upon theorganization, a political milieu that supports mentalhealth service delivery, and societal norms and subcul-tures that affect consumers' access to EBPs. Therefore, pol-icymaking that is focused exclusively toward clinicians isunlikely to be sustainable; instead, policymakers need toalign the effects of policy action across all of these contextsin order to produce 'sustained, systemwide uptake' ofEBPs. Implementation researchers designing and con-ducting implementation studies even at the level of a sin-gle organization need to be cognizant of influences atmultiple levels of the organization that can affect theirchances of success. In the remainder of this article, wedescribe a policy ecology framework for EBP implementa-tion, and identify policy levers (i.e. strategies that policy-makers can deploy) at each of these contexts – other thanat the level of the individual client/practitioner encounter– that, when addressed, can result in sustainable uptake ofEBPs (Figure 1).Policy levers at the organizational levelOrganizations – ranging from small mental health prac-tice associations to large, multidisciplinary mental healthfacilities – form the immediate context within which mostclinicians deliver mental health interventions to consum-Table 1: Summary of Strategies for PolicymakersLevel in the Policy Ecology StrategyProvider organizationDeveloping flexible and enhanced reimbursement strategies that accommodate the increased costs of EBP implementation.Re-engineering continuing education units to support training in EBPs, auditing and feedback, and disallowing of certain courses for CEU credit.Influencing the type of care purchased by changing contracting and bidding procedures.Considering expansion of disease management programs as a model for comprehensive EBP implementation.Using procedural mechanisms such as prior authorization to support specific EBPs.Developing and measuring client-level outcomes to assess the effectiveness of EBPs, and aligning purchasing to the attainment of these outcomes.Carefully considering enabling legislation to purchase EBPs.Legislating mental health parity, and supporting the reduction of stigma and discrimination of individuals with mental health diagnoses.Legislating loan forgiveness programs for providers who adopt and promote the use of EBPs.Identifying and eliminating structural stigma in all legislation.Involving consumer advocates at all levels of implementation.Reducing stigma and discrimination that can prevent access to needed mental health services, including EBPs.Regulatory or purchaser agencyPoliticalSocial

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Implementation Science 2008, 3:26http://www.implementationscience.com/content/3/1/26Page 4 of 9(page number not for citation purposes)ers. Attempting to deliver new evidence-based interven-tions within organizations is associated with severalchallenges [7,30]; however, once organizations determinethat a particular function, such as delivering EBPs to a par-ticular population, is part of their core mission, they tendto protect these technical functions from what RobertRosenheck describes as the 'stormy sea of organizationalprocess' [30]. In addition to protecting core functions,some 'learning organizations' [31] actively seek out waysto improve their core missions [32], through promotinginquiry, connection, and opportunities to learn and grow[33]. Policymakers can incentivize, and researchers canfind ways to enhance, both of these organizational actions– protecting the delivery of EBPs, and actively engaging inquality improvement efforts – in two ways.First, most EBPs are associated with higher marginal coststhat need to be reimbursed. These costs are generated byproviders, organizations, and state agencies, and several ofthese costs accrue to organizations. Examples include thecosts of training in EBPs, costs of ongoing supervision andcase consultation, productivity losses as novice cliniciansgain mastery in new interventions, and the costs of docu-mentation and regulatory compliance. Existing reim-bursement strategies rarely cover these higher costs, whichare currently borne largely by organizations. By develop-ing enhanced reimbursement strategies [34] that cover themarginal costs of implementation, mental health pur-chasers can ensure a more sustainable organizational con-text for EBPs.Second, much of organizational learning occurs throughcontinuing education and related professional develop-ment activities by its licensed professionals. Regulationssurrounding mandated continuing education units(CEUs) offer policymakers the ability to shape profes-sional practice toward EBPs. State licensing board regula-tors, or their interagency partners, can assume all costs of,or subsidize, certain CEUs, provide direct technical assist-ance in developing courses and programs, or disallow cer-tain courses for licensing credit. However, in order topromote an EBP environment, licensing boards will needto reconsider the structure of the CEU. Because single-shottraining and didactic approaches are usually ineffective inshaping provider behavior, licensing boards will need tosupport quality improvement approaches that are rootedin the literature on provider behavioral change [35-38].This literature suggests that provider education needs tobe combined with auditing and feedback, as well asreminder systems and real-time decision support in orderto be truly effective [38]. Re-engineering CEUs can helpaddress an issue raised in a recent report issued by aNational Institute of Mental Health (NIMH) workgroup,which noted a dearth of professionals adequately trainedto provide EBPs [39].Policy levers at the regulatory and purchasing agency levelRegulatory and purchasing agencies form the immediatepolicy context for organizational activity in mental health,and have a long history of quality improvement. First-gen-eration efforts undertaken by purchasers focused largelyon profiling providers and hospitals. For example, Con-gress required the establishment of the National ProviderData Bank (which assists credential review of providers bystate licensing boards, hospitals, and other health careentities) [40], and over 30 states make available physicianprofiles to the public [41]. Second-generation effortsdirected at quality improvement largely involved manag-ing quantity. For example, the rise of Medicaid managedcare saw the increasing use of utilization review (or man-agement) covering a variety of inpatient and ambulatoryservices [42].Third-generation efforts, currently underway in almost allstates, are designed to enhance the appropriateness of careby monitoring the type of care that is delivered, and canserve as models to support the implementation of EBPs.States can influence the type of care they pay for by usingcontractual requirements during the bidding process forpurchase of services. In general, states tend to use fiveprincipal types of fiscal incentives – pay-for-performanceor other payment incentive mechanisms, reduction inoversight and other regulatory requirements, fast-trackingor providing other advantages in the competitive biddingprocess, paying for infrastructure (such as free training inEBPs), and some sort of public recognition or award forproviding EBPs [43]. The Ohio Departments of MentalHealth and Alcohol and Drug Addiction Services haveestablished coordinating centers to provide training,supervision, consultation, and other types of informationsharing to support implementation of EBPs [44]. How astate structures its contracts to purchase EBPs is likely to behighly idiosyncratic, requiring a mix of financing and reg-ulatory change, addressing issues of leadership and organ-izational politics, and ensuring training and datamanagement efforts [45].Second, some states have undertaken quality improve-ment within a disease management framework, defined as'... a system of coordinated healthcare interventions andcommunications for populations with conditions inwhich patient self-care efforts are substantial' [46]. Whilethe specific components of a disease management pro-gram vary, common elements of all such programsinclude a systematic way of identifying patients; matchingthe intervention with their needs; ensuring the availabilityof EBP guidelines for not only physicians but also for allother providers involved in the care of the disease; devel-oping an individualized treatment plan for the uniqueneeds of the patient; designing services that promotepatient adherence to this individualized treatment plan

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Implementation Science 2008, 3:26 http://www.implementationscience.com/content/3/1/26Page 5 of 9(page number not for citation purposes)through such mechanisms as patient education, monitor-ing and reminders, and behavior modification programs;systematically collecting process and outcome measures;and providing a way for physicians, other providers, andthe patient to obtain ongoing feedback on how care isprogressing and what outcomes are being met [47]. Suc-cessful implementation of disease management programsin commercial health plans led to the establishment of thefirst Medicaid disease management program – Virginia'sprogram for asthma – in the early 1990s [46]. Floridaestablished the nation's first disease management pro-gram for a mental disorder (major depression), and theCenters for Medicare and Medicaid Services (CMS) havefunded a national disease management demonstrationproject [48]. Disease management programs in publicmental health settings are most likely to be successful forconditions that are stable over time, that can be reliablyidentified through screening instruments, that have well-developed and tested interventions suitable for imple-mentation, and that require a comprehensive array ofservices. Conditions such as childhood trauma, for exam-ple, offer an opportunity for the construction of diseasemanagement programs, which can serve as a vehicle forthe implementation of EBPs for this condition [49,50].Third, prior authorization – the requirement that provid-ers obtain approval for the use of a particular interventionor drug – is an existing approach used by over 30 states[51]. Originally developed as a cost-containment measureto control pharmacy costs, prior authorization is oftencombined with formularies to restrict the variety of medi-cations available to beneficiaries. Although little experi-ence exists with prior authorization for behavioralinterventions, such programs could be used to restrictpotentially harmful interventions being delivered toenrollees. Conversely, eliminating evidence-based inter-ventions from restrictions on session limits, modifyingdesignated patient regulations that restrict who canreceive the service, and modifying existing regulationsgoverning session lengths can all serve to promote EBPsusing this approach.Fourth, many states have experience with provider profil-ing, which can be used to promote an EBP agenda.Attempts to improve the appropriateness of psychotropicmedication use, for example, have seen the use of pro-vider-level audits of prescriptions, a practice called pre-scriber profiling. While attempts are underway to reducesharing of prescriber data with pharmaceutical companies[52], state purchasers can, and do, access prescriber-levelrecords to identify individuals engaging in aggressivepharmacotherapy, and to monitor compliance with estab-lished medication algorithms [53]. However, few statesseem to have implemented 'psychotherapy profiling' sys-tems, which may allow therapists with specialized train-ing to be identified and reimbursed at a higher rate.Psychotherapy profiling will require states to develop spe-cialized billing codes that would permit comprehensiveassessments [54,55], which could guide deployment ofEBPs. States may also need to modify their billing require-ments to accommodate EBPs that differ structurally fromindividual or group therapy.Finally, states will need to find a way to link all such pro-cedural efforts with individual client-level outcomes. Out-come measures in mental health are difficult andexpensive to administer, which is why most qualityimprovement efforts focus on performance or processindices. However, federal policymaking seems to be mov-ing toward requiring comprehensive outcome measuresas a condition of payment – such as the requirement thatall home health agencies seeking Medicare certificationreport on a set of common measures contained in theOutcome and Assessment Information Set (OASIS) [56].SAMHSA's national outcome measures (NOMs) also out-line a series of client-level as well as systemic outcomesacross ten domains [29], although there is not yet a linkbetween purchasing and attainment of these measures. Todate, few states have established mechanisms to collectdata on performance indicators statewide [29], and nonehave established statewide client-level outcomes monitor-ing. Developing or adopting outcomes assessment, eitherstatewide or within a given system (e.g. children's mentalhealth) is a necessary first step for any outcomes-basedreimbursement approach as a tool to support EBP imple-mentation.Policy levers at the political levelWe define the political context of EBP implementation asinvolving all legislative and advocacy efforts that supportsuch a goal. While few laws are directed specifically atimplementation efforts, legislation often forms the ena-bling resource for EBP implementation. For example, fol-lowing Oregon's 2003 legislation (discussed earlier), theIowa legislature passed in 2004 a law that extended anEBP mandate beyond state agencies, requiring commu-nity mental health centers to spend an increasing share ofMental Health Block Grant dollars in purchasing EBPs[57]. Policymakers will need to carefully weigh the natureof the evidence, the availability of local resources todeliver the EBP with fidelity, and the unintended conse-quences of micromanaging care before considering suchlegislative strategies.While much of the focus of EBP activists has been on suchtargeted laws, other laws, such as mental health paritylaws, also require attention by state policymakers. Theselaws have a broader objective – ensuring that mentalhealth services can be adequately resourced and delivered– which is a necessary requisite for providing EBPs. The

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Implementation Science 2008, 3:26http://www.implementationscience.com/content/3/1/26Page 6 of 9(page number not for citation purposes)issue of mental health parity extends far beyond providingnecessary resources, however, in being intimately relatedto social-level issues of stigma, misunderstanding, anddiscrimination toward people with mental health diag-noses [58]. Parity legislation, therefore, is necessary butinsufficient to drive implementation efforts due to thesesocietal factors, which we consider in greater detail below.Third, another way in which state legislatures can incen-tivize EBP implementation is by passing laws that reduceor forgive educational debts for professionals who adoptand promote EBPs. Debt forgiveness is currently used topromote health sciences, counseling, and social workpractice in high-need areas with particularly vulnerablepopulations, based on federal legislation [59-61]. By re-conceptualizing an underserved area as extending beyondgeography to types of practice, legislation could provideforgiveness of educational debt to clinicians deliveringEBPs to defined populations, and make EBP-trained clini-cians more financially attractive to employers.Fourth, policymakers can begin to reduce or eliminatestructural stigma. Structural stigma refers to state policiesor legislation that deliberately deprive certain groups ofindividuals (in this case, the mentally ill) from the rightsand privileges that accrue to other groups. A 1999 surveyof state laws revealed that 44 states imposed some restric-tions on the rights of mentally ill individuals to serve on ajury, 37 imposed restrictions on their voting, 23 imposedrestrictions on their holding elective office, and 27imposed restrictions on their parental rights [62]. An anal-ysis of the 968 mental health bills introduced into legisla-tures nationwide in calendar year 2002 revealed thatalthough most states were legislating to protect the rightsof mentally ill individuals, some states were expandingrestrictions of parental rights for the mentally ill [63].While we are unaware of examples of structural stigmathat affect EBPs, legislators will need to pay close attentionto the effects of their EBP-related lawmaking in order toavoid discriminating against mental health consumers.Fifth, policymakers who look to support for an EBPagenda from consumer-focused advocacy groups will findthat these groups have not been universally supportive ofthe emergence of EBPs. On one hand, there is an appreci-ation of a model of practice built upon documentedresults rather than on the opinions of experts [64], andorganizations such as the National Alliance for the Men-tally Ill have supported some EBP implementation efforts[65]. Professional organizations are generally strong sup-porters of EBPs, have testified before Congress [66], andhave set up task forces to promote such practices [67],among other efforts. Conversely, consumer-directedadvocacy groups, such as the National Mental HealthConsumer's Association, have advanced equivocal posi-tions [65]. Several family/consumer fears have been doc-umented in the literature [7], and include concerns thatthe EBP movement is insufficiently aligned with therecovery model (in which mental health consumers arepresumed capable of making considerable progresstoward independence [68]), that EBPs may replace otherneeded services, that there may be a lack of availability ofproviders able to deliver EBPs, that EBPs may be undulyprescriptive and cause consumers to lose control overtheir care, and that they may not be sufficiently culturallycompetent [6,69].Policymakers who confront such issues may benefit froman approach to engaging consumers and families pro-posed by Birkel and colleagues [70], who suggest that EBPimplementation efforts should actively build collabora-tive relationships at the beginning of the implementationprocess; should find ways to integrate recovery in thedevelopment and deployment of EBPs; should pay specialattention to racial/ethnic, geographical, cultural and lin-guistic diversity in all implementation efforts; and shoulddevelop and disseminate resources to support not just theEBP but also its advocacy. Such an inclusive approach topolicymaking that takes into account diverse consumerand family needs may be necessary to assure widespreadacceptability of EBPs.Policy levers at the social levelSeveral efforts discussed above, including those focusedon consumer advocacy, cultural competence, and consen-sus-building, lie at the interface between political andsocial contexts of EBP implementation. In this section, wefocus on how policymakers can mitigate the effects ofstigma in preventing access to EBPs.Combating mental health-related stigma is a goal of thePresident's New Freedom Commission [71], and is essen-tial because access to EBPs is conditional upon access tomental health services. Several EBPs also require greateramounts of adherence to protocols, which can be com-promised in the presence of stigma. However, empiricalguidance for policymakers on ways to reduce stigma is stillemerging. The NIMH established a Stigma WorkingGroup in 1999, and has issued a program announcementto fund research projects on stigma reduction [72].SAMHSA established its Eliminating Barriers Initiative in2003, and funds a Resource Center to Address Discrimina-tion and Stigma [73]. These efforts aim to identify effec-tive approaches to reduce stigma and discrimination, suchas those involving public educational programming, pro-ducing educational materials, contact-based approaches,and public service announcements. Other efforts at end-ing stigma use social marketing principles. For example,the World Health Organization's 2001 World Health Daylaunched an international campaign to reduce stigma

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Implementation Science 2008, 3:26 http://www.implementationscience.com/content/3/1/26Page 7 of 9(page number not for citation purposes)associated with mental illnesses among youth, whichincluded organization of school contests addressingstigma, development of teacher guides, production of abook on stigma through children's eyes, and a curriculumfor use in health education programs worldwide [74,75].While reducing stigma may be an educational endeavor,eliminating discrimination is usually a legal process. Pol-icy approaches that can serve more proximal goals of end-ing discrimination include treatment and care for individuals with mental illnesses,supporting effective public and professional education,and preserving mental health allotments in health, wel-fare, and research budgets [76]. While none of theseapproaches directly serve an EBP implementation agenda,they create the contexts for improved access to mentalhealth services, within which an EBP agenda can be sup-ported.ensuring appropriateSummaryEfforts to improve the quality of mental health servicesshould consider the larger ecology that is known to affectimplementation instead of solely focusing on specificinterventions and the specific locations of their delivery.An integrated approach to policymaking at several levelsof this ecology – as summarized in Table 1 – can supporta more sustainable, and ultimately more successful,implementation process. In addition, implementationresearchers need to be aware of influences at multiple lev-els of this ecology; absent a conducive environment, gainsfrom even the best-designed approaches targeted solely atindividual providers or organizations are unlikely to per-sist over the long term. Implementation researchers willalso need to build in the systematic collection of data atmultiple levels of the implementation ecology whiledesigning their studies in order to identify and test changestrategies that are likely to succeed. Practice leaders, suchas executive directors of mental health organizations, areusually highly attuned to the environment within whichtheir organizations operate, and will be important sourcesof information on, and change agents in, this ecologicalapproach to implementation. We recommend that allindividuals involved with implementation efforts con-sider these strategies as they collectively strive to increasethe availability of EBPs to vulnerable populations.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsRR conceived this manuscript, and led the writing. CLBassisted with the literature review, and wrote parts of thismanuscript. ALS participated in the conceptualizationand writing of this manuscript.AcknowledgementsDr. Raghavan is an investigator with the Center for Mental Health Services Research, at the George Warren Brown School of Social Work, Washing-ton University in St. Louis; through an award from the National Institute of Mental Health (5P30 MH068579).References1.Ganju V: Implementation of evidence-based practices in statemental health systems: implications for research and effec-tiveness studies. Schizophrenia bulletin 2003, 29:125-131.2.Evidence-Based Medicine Working Group: Evidence-Based Medi-cine. A New Approach to Teaching the Practice of Medicine.JAMA 1992, 268:2420-2425.3.Guyatt GH: Evidence-Based Medicine. Annals of Internal Medicine1991, 114:A-16.4.Hoagwood K, Burns BJ, Kiser L, Ringeisen H, Schoenwald SK: Evi-dence-Based Practice in Child and Adolescent MentalHealth Services. 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Fam-ily & Community Health 2007, 30:93-111.10. U.S. Department of Health and Human Services Agency for HealthCare Policy and Research: Using Clinical Practice Guidelines toEvaluate Quality of Care. Rockville, MD: U.S. Department ofHealth and Human Services; 1995. 11.Huttin C: The Use of Clinical Guidelines to Improve MedicalPractice: Main Issues in the United States. Int J Qual Health Care1997, 9(3):207-214.12.U.S. Department of Health and Human Services Agency for Health-care Research and Quality: 2006 National Healthcare QualityReport. Rockville, MD: U.S. Department of Health and Human Serv-ices; 2006. 13. Oregon Office of Mental Health and Addiction Services: ProjectPlan to Promote the Adoption of Evidence-Based Practices.2004.14.Texas Medication Algorithm www.dshs.state.tx.us/mhprograms/TMAP.shtm]15.Tanenbaum SJ: Evidence-Based Practice as Mental Health Pol-icy: Three Controversies and a Caveat. Health Affairs 2005,24:163-173.16.U.S. Department of Health and Human Services Substance Abuse andMental Health Services Administration: National Outcome Meas-ures. Rockville, MD: USDHHS, Substance Abuse and Mental HealthServices Administration; 2007. 17.Ferlie EB, Shortell SM: Improving the Quality of Health Care inthe United Kingdom and the United States: A Frameworkfor Change. Milbank Quarterly 2001, 79:281-315.18.Malik AM: Quality Improvement Issues in Brazil. Joint Commis-sion Journal on Quality and Safety 1997, 23:55-59.19.Paeger A: Quality Improvement in Germany. Joint CommissionJournal on Quality and Safety 1997, 23:38-46.20.U.S. Department of Health and Human Services Substance Abuse andMental Health Services Administration: FY 2005 SAMHSA GrantAwardees – CMHS. 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[Show abstract][Hide abstract]ABSTRACT: This research focused on the relationships between a national team and five project sites across Canada in planning a complex, community intervention for homeless people with mental illness called At Home/Chez Soi, which is based on the Housing First model. The research addressed two questions: (a) what are the challenges in planning? and (b) what factors that helped or hindered moving project planning forward? Using qualitative methods, 149 national, provincial, and local stakeholders participated in key informant or focus group interviews. We found that planning entails not only intervention and research tasks, but also relational processes that occur within an ecology of time, local context, and values. More specifically, the relationships between the national team and the project sites can be conceptualized as a collaborative process in which national and local partners bring different agendas to the planning process and must therefore listen to, negotiate, discuss, and compromise with one another. A collaborative process that involves power-sharing and having project coordinators at each site helped to bridge the differences between these two stakeholder groups, to find common ground, and to accomplish planning tasks within a compressed time frame. While local context and culture pushed towards unique adaptations of Housing First, the principles of the Housing First model provided a foundation for a common approach across sites and interventions. The implications of the findings for future planning and research of multi-site, complex, community interventions are noted.

[Show abstract][Hide abstract]ABSTRACT: An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of "implementation outcomes" distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working "taxonomy" of eight conceptually distinct implementation outcomes-acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability-along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.

[Show abstract][Hide abstract]ABSTRACT: The objective of this study is to examine the characteristics of outpatient mental health services delivered in community-based outpatient clinics, comparing information obtained from two different sources, therapists serving children and families, and observational coders viewing tapes of the same treatment sessions. Videotaped therapy sessions were rated by therapists and independent coders regarding goals and strategies pursued during each session. Sixty-three sessions were taped of outpatient care provided to 18 children and their caregivers by 11 therapists. Children were 4-13 years old and families were receiving services at least in part due to reported child behavior problems, confirmed by ratings from the Child Behavior Checklist and Conners Parent Rating Scale-Revised. Analyses assessed the frequency, type, and intensity of goals and strategies pursued in therapy sessions from both therapist and observational coders' perspectives. Reliability of observer ratings and correspondence between therapist and observer reports were also examined. The reliability of observational coding of goals and strategies was moderate to good, with 76% of 39 codes having ICCs of .5 or greater. Therapists reported pursuing 2.5 times more goals and strategies per session, on average, than identified by observational coders. Correspondence between therapists and coders about the occurrence of specific goals and strategies in treatment sessions was low, with 20.5% of codes having a Kappa of .4 or higher. Substantial differences exist in what therapists and independent coders report as occurring in outpatient treatment sessions. Both perspectives suggest major differences between the content of services provided in community-based outpatient clinics and the structure of evidence-based programs, which emphasize intense pursuit of a small number of goals and strategies in each treatment session. Implications of the findings for quality improvement efforts in community-based mental health care settings are discussed.